Decentralising screening and preventive treatment among children exposed to tuberculosis in the household
Authors: Florian M Marx, Abigail de Villiers
Journal: The Lancet Global Health (2023)

Tuberculosis remains a considerable cause of morbidity and death among children globally. WHO estimated that, in 2021, a total of 1·15 million children aged 0–14 years fell ill with tuberculosis and nearly 217 000 died from the disease.1WHOGlobal tuberculosis report.https://www.who.int/teams/global-tuberculosis-programme/tb-reports/global-tuberculosis-report-2022Date: 2022Date accessed: October 26, 2023Google Scholar An estimated 80% of these tuberculosis-related deaths occurred in children younger than 5 years.2Dodd PJ Yuen CM Sismanidis C Seddon JA Jenkins HE The global burden of tuberculosis mortality in children: a mathematical modelling study.Lancet Glob Health. 2017; 5: e898-e906Summary Full Text Full Text PDF PubMed Scopus (262) Google Scholar Exposure to tuberculosis within the household is known to be a key driver of childhood tuberculosis. An individual participant data meta-analysis suggested that the risk of tuberculosis among exposed children is very high, with 19% of those younger than 5 years developing tuberculosis within 2 years in the absence of tuberculosis-preventive treatment (TPT).3Martinez L Cords O Horsburgh CR Andrews JR The risk of tuberculosis in children after close exposure: a systematic review and individual-participant meta-analysis.Lancet. 2020; 395: 973-984Summary Full Text Full Text PDF PubMed Scopus (158) Google Scholar The importance of providing contact management for children exposed to tuberculosis in the household is well recognised.4WHOWHO consolidated guidelines on tuberculosis: module 1: prevention: tuberculosis preventive treatment.https://www.who.int/publications/i/item/9789240001503Date: Feb 25, 2020Date accessed: October 26, 2023Google Scholar Mathematical modelling suggests that scaling up household contact management, including TPT, could substantially reduce childhood tuberculosis incidence and mortality globally.5Dodd PJ Yuen CM Becerra MC Revill P Jenkins HE Seddon JA Potential effect of household contact management on childhood tuberculosis: a mathematical modelling study.Lancet Glob Health. 2018; 6: e1329-e1338Summary Full Text Full Text PDF PubMed Scopus (53) Google Scholar However, household contact management and TPT remain poorly implemented in many countries. Between 2018 and 2021 globally, only 1·6 million household contacts younger than 5 years received TPT: 60% short of the 5-year (2018–22) 4 million target set by WHO.1WHOGlobal tuberculosis report.https://www.who.int/teams/global-tuberculosis-programme/tb-reports/global-tuberculosis-report-2022Date: 2022Date accessed: October 26, 2023Google Scholar To accelerate progress, WHO promotes the use of decentralised and family-centred, integrated models of care to deliver child and adolescent tuberculosis services in high-burden settings.6WHOWHO consolidated guidelines on tuberculosis: module 5: management of tuberculosis in children and adolescents.https://www.who.int/publications/i/item/9789240046764Date: March 18, 2022Date accessed: October 26, 2023Google Scholar Although community-based models of household contact management and TPT have been studied,7Kay AW Sandoval M Mtetwa G et al.Vikela Ekhaya: a novel, community-based, tuberculosis contact management program in a high burden setting.Clin Infect Dis. 2022; 74: 1631-1638Crossref PubMed Scopus (13) Google Scholar no randomised controlled trial had previously been conducted to directly compare a decentralised approach with the standard of care. In The Lancet Global Health, Maryline Bonnet and colleagues8Bonnet M Vasiliu A Tchounga BK et al.Effectiveness of a community-based approach for the investigation and management of children with household tuberculosis contact in Cameroon and Uganda: a cluster-randomised trial.Lancet Glob Health. 2023; (published online Oct 30.)https://doi.org/10.1016/S2214-109X(23)00430-8Summary Full Text Full Text PDF Scopus (3) Google Scholar report the findings of a large cluster-randomised trial in Cameroon and Uganda involving 2894 children who were exposed to tuberculosis within their households, 1400 of whom were eligible for TPT. The trial compared a decentralised approach, under which tuberculosis contact investigation and TPT were delivered by community health workers in households (intervention), with the standard of care, under which these services were provided by routine staff in health-care facilities (control). TPT comprised a 3-month regimen of daily isoniazid–rifampicin. The trial found that among children declared as contacts by index patients, more children were screened for tuberculosis under the household-based intervention (1548 [81·9%] of 1889) than under the standard of care (475 [47·3%] of 1005).8Bonnet M Vasiliu A Tchounga BK et al.Effectiveness of a community-based approach for the investigation and management of children with household tuberculosis contact in Cameroon and Uganda: a cluster-randomised trial.Lancet Glob Health. 2023; (published online Oct 30.)https://doi.org/10.1016/S2214-109X(23)00430-8Summary Full Text Full Text PDF Scopus (3) Google Scholar The intervention also resulted in a higher number of additional children being screened who were household contacts per the WHO definition but who had not been initially declared by the index patient. Among child contacts eligible for TPT, TPT was initiated and completed by 752 (79·9%) of 941 children in the intervention group and 283 (61·7%) of 459 in the control group. Operational issues related to travel or transport were found to be the primary reason for TPT discontinuation in the control group.8Bonnet M Vasiliu A Tchounga BK et al.Effectiveness of a community-based approach for the investigation and management of children with household tuberculosis contact in Cameroon and Uganda: a cluster-randomised trial.Lancet Glob Health. 2023; (published online Oct 30.)https://doi.org/10.1016/S2214-109X(23)00430-8Summary Full Text Full Text PDF Scopus (3) Google Scholar In a related Article, Nyashadzaishe Mafirakureva and colleagues9Mafirakureva N Tchounga BK Mukherjee S et al.Cost-effectiveness of community-based household tuberculosis contact management of children in Cameroon and Uganda: a modelling analysis of a cluster-randomised trial.Lancet Glob Health. 2023; (published online Oct 30.)https://doi.org/10.1016/S2214-109X(23)00451-5Summary Full Text Full Text PDF PubMed Scopus (3) Google Scholar report on the health impact and cost-effectiveness of the household-based intervention using data from the trial. They estimated that the intervention prevented 10–15 tuberculosis deaths among children for every 1000 index patients involved in the study setting. Mean incremental cost-effectiveness ratios under the household-based model were $620 per disability-adjusted life-year (DALY) averted in Cameroon and $970 per DALY averted in Uganda, relative to the standard of care. Of note, the analysis adopted a health-care system perspective and, therefore, did not consider important societal benefits, such as cost savings to families for avoiding travel to health-care facilities. Bonnet and colleagues and Mafirakureva and colleagues are to be commended for their important studies and rigorous analyses, generating evidence that a decentralised, community-based model of household contact management and TPT can substantially strengthen tuberculosis prevention and care among exposed children. Estimates of incremental costs per additional DALY averted under this decentralised approach compare reasonably well with those for scaling up child contact management and TPT in other high-burden countries10Jo Y Gomes I Flack J et al.Cost-effectiveness of scaling up short course preventive therapy for tuberculosis among children across 12 countries.EClinicalMedicine. 2021; 31100707 Summary Full Text Full Text PDF PubMed Scopus (13) Google Scholar and provide an impetus to seriously consider investment in community-based models to strengthen tuberculosis prevention and care among children. The findings from both studies also contribute to the broader discussion about the benefits of decentralising essential health-care services to better reach children and families in need. This discussion also includes questions about additional resources required for established health-care services to become more accessible, and about the roles of community health workers in delivering health services. The cluster-randomised trial by Bonnet and colleagues8Bonnet M Vasiliu A Tchounga BK et al.Effectiveness of a community-based approach for the investigation and management of children with household tuberculosis contact in Cameroon and Uganda: a cluster-randomised trial.Lancet Glob Health. 2023; (published online Oct 30.)https://doi.org/10.1016/S2214-109X(23)00430-8Summary Full Text Full Text PDF Scopus (3) Google Scholar represents an important milestone to demonstrate that decentralised provision of household contact management and TPT can significantly strengthen tuberculosis prevention and care among children. Additional work must follow to assess the effectiveness, cost, and budget implications of this approach under real-life conditions, outside of a well funded trial. Determining how this strategy can be packaged with other services to yield additional health benefits for families affected by tuberculosis—including, for example, treatment monitoring and support for the index patient—will be important. The findings of Bonnet and colleagues8Bonnet M Vasiliu A Tchounga BK et al.Effectiveness of a community-based approach for the investigation and management of children with household tuberculosis contact in Cameroon and Uganda: a cluster-randomised trial.Lancet Glob Health. 2023; (published online Oct 30.)https://doi.org/10.1016/S2214-109X(23)00430-8Summary Full Text Full Text PDF Scopus (3) Google Scholar and Mafirakureva and colleagues9Mafirakureva N Tchounga BK Mukherjee S et al.Cost-effectiveness of community-based household tuberculosis contact management of children in Cameroon and Uganda: a modelling analysis of a cluster-randomised trial.Lancet Glob Health. 2023; (published online Oct 30.)https://doi.org/10.1016/S2214-109X(23)00451-5Summary Full Text Full Text PDF PubMed Scopus (3) Google Scholar serve as a poignant reminder that we possess the means and tools to be more successful in reducing the suffering and death caused by tuberculosis among children worldwide. We declare no competing interests. Effectiveness of a community-based approach for the investigation and management of children with household tuberculosis contact in Cameroon and Uganda: a cluster-randomised trialA community-based approach using community health workers can significantly increase contact investigation coverage and TPT completion among eligible child contacts in a tuberculosis-endemic setting. Full-Text PDF Open AccessCost-effectiveness of community-based household tuberculosis contact management for children in Cameroon and Uganda: a modelling analysis of a cluster-randomised trialCommunity-based HCM approaches can substantially reduce child tuberculosis deaths and in our case would be considered cost-effective at willingness-to-pay thresholds of $1000 per DALY averted. Their impact and cost-effectiveness are likely to be greatest where baseline HCM coverage is lowest. Full-Text PDF Open Access